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In the previous articles we have considered the law relating to the discharge of still vulnerable patients from hospital. Admission to hospital can be traumatic, leading to disorientation and a loss of confidence. But with proper support during a transition period, a person may be able to return home.

Without it, they may be consigned to the system of residential care with its associated expense and the loss of their life as they knew it. This article considers the help that may be available to give the best chance for an older person to return home

Intermediate care has a strict legal definition contained in regulation 2 Community Care (Delayed Discharges) Act (Qualifying Services) (England) Regulations 2003 which states that it is a “structured programme of care provided for a limited period of time to assist a person to maintain or regain the ability to live in his home.”

Cost of Intermediate care

Financial responsibility for intermediate care has rested with local authorities. Under the regulations, intermediate care is to be provided free for the first 6 weeks. A programme can last for longer than 6 weeks, but following this the individual should be means tested.

In 2010 an investigation by the periodical “Community Care” identified that many local authorities were charging for intermediate care from the outset.

The Department of Health issued guidance[2] reminding local authorities that “re-ablement services are likely to fall within the definition of intermediate care services and should not be charged for the first six weeks.” The circular stated that additional funds would be provided to primary care trusts in that year to disburse on intermediate care services, working in conjunction with social service departments.

Does the law need updating? (paraupdated 13.3.2012)

The government had proposed that from April 2012, hospitals would be responsible for the first 30 days of home care after discharge from hospital. This was confirmed in a Department of Health Circular, LAC 2010(6). The provision of re-ablement was a particular focus. The year 2011-12 was to be a year of transition.

It appears that full implementation of this policy has been delayed. In response to an FOI request sent by the author, the Department of Health has stated:-

“Whilst the Government had previously announced a policy intention to transfer from commissioners to providers the responsibility for care for 30 days after discharge, this policy has not yet been introduced in full.
In 2012/13 the shift of responsibility is restricted to patients needing post-discharge support for cardiac rehabilitation, chronic obstructive pulmonary disease rehabilitation, knee replacement or hip replacement.”

To the extent that this policy is implemented, the Community Care (Delayed Discharge) Act 2003 and the accompanying regulations now require an overhaul. Their purpose was to get patients out of hospital by penalising social services departments who shunted care costs on to the NHS by delaying the implementation of necessary care packages for which they were responsible. The primary involvement of a local authority in the discharge process would then have been to advise the hospital on care planning post discharge, rather than act as paymaster for those packages. Given the restrictions on the extent of 30 day support, the operation of the Act now has an added complexity

The 2009 guidance notes that those at risk of being placed in residential care inappropriately should be a priority for preventative support.

It states that :-

All older people at risk of entering care homes, either residential or nursing, should be given the opportunity to benefit from rehabilitation and recuperation and for their needs to be assessed in a setting other than an acute hospital ward.

They should not be transferred directly to long-term residential care from an acute hospital ward unless there are exceptional circumstances. Such circumstances might include:

those who have already completed a period of specialist rehabilitation, such as in a stroke unit

those judged to have had sufficient previous attempts at being supported at home (with or without intermediate care support)

those for whom a period in residential intermediate care followed by another move is judged likely to be distressing.

Although this is best practice guidance and therefore not legally binding, the reference to exceptional circumstances is strongly worded and it should be difficult for local authorities and the NHS to act contrary to this.

The 2009 guidance notes that intermediate care is suitable for people whose short term needs can be met within a period of weeks. Whilst 6 weeks may be the limit of free care, there should be no expectation that a package of intermediate care will last that long. It should last for shorter periods where appropriate.

There should be a holistic assessment of need and the patient and carers should be consulted. A care plan should be produced.

What services may be relevant?

The services that may assist discharged patients or prevent an admission in the first place include:-

residential rehabilitation in a setting such as a residential care home or community hospital, for people who do not need 24-hour consultant-led medical care but need a short period of therapy and rehabilitation, ranging from one to about six weeks

supported discharge in a patient’s own home, with nursing and/or therapeutic support, and home care support and community equipment where necessary, to allow rehabilitation and recovery at home. The arrangements may work well in specialist accommodation such as extra care housing

day rehabilitation for a limited period in a day hospital or day centre, possibly in conjunction with other forms of intermediate care support.

rapid response teams to prevent avoidable admission to hospital for patients referred from GPs, A&E or other sources, with short-term care and support in their own home

acute care at home from specialist teams, including some treatment such as administration of intravenous antibiotics

Conclusion

The effectiveness of intermediate care programmes in a geographic area will depend substantially on effective joint working between health and social services. This has always been problematic in the past. Lack of co-ordination is a widely recognised problem and some local authorities and NHS bodies have addressed this more effectively than others.

The transfer of responsibility to the NHS for care for the first 30 days post discharge may assist in resolving some of the financial conflicts of interest that have hampered the provision of effective intermediate care in the past.

Given the pressing needs of a person in hospital, the guidance will be of no assistance if an enquiry about intermediate care is simply met with a blank look and a cry of “we don’t do that.” But the enquiry should be pressed because fledgling services may be available and will benefit if the public demands them.

The next article will deal with the issue of equipment and adaptations for the patient who has been discharged home.